BARBARA K. CEGAVSKE Secretary of State 555 East Washington Ave., #5200 Las Vegas, Nevada 89101 (702) 486-2880 Website: www.nvsos.gov *190603* Application for Registration of Claim to Right of Publicity (PURSUANT TO NRS 597.800) USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY 1. Name of Claimant: 2. Address of Claimant: 3. The above listed claimant, being first duly sworn, under penalty of perjury, deposes and says that he is the: (check only one box) Successor In Interest Licensee of the deceased person identified below. 4. Legal name of the deceased person: 5. Professional name of the deceased person: 6. Date of death of deceased person: 7. The basis of the claimant's claim is as follows: 8. The following is a description of the rights claimed: STATE OF COUNTY OF This instrument was signed and sworn to before me on by Date Claimant X Signature of Claimant Notary Stamp Filing Fee: $25.00 Notary Signature American LegalNet, Inc. www.FormsWorkFlow.com Nevada Secretary of State Right of Publicity Revised: 1-5-15